II. Medicalized Midwifery Morphs into the surgical speciality of the “New Obstetrics”

by faithgibson on November 26, 2012

History – Medicine and Midwifery – Part II

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The core of organized medicine’s plan to eliminate midwives from the practice of midwifery was the idea that ‘modern’ obstetrics was no longer a general practice of medicine but had instead  become a new surgical discipline.

The proper scope of practice identified for the ‘new obstetrics was childbirth in all its forms and circumstances, which included healthy women with normal pregnancies, as well those suffering from the complications of pregnancy and childbirth.

Having defined normal childbirth to be surgical procedure and identified healthy childbearing women as the patients of a surgical speciality obviously eliminated the entire category of midwives as birth attendants. Public pronouncements about the wonders of  the ‘new’ obstetrics as a modern surgical discipline were accompanied by legal and legislative attempts to diminish and eventually abolish the lawful practice of midwives. From the standpoint of medical profession, the big issue was surgical skills, which was something that only doctors were educated and licensed to provide. According to this philosophy, midwifery care as provided by midwives amounted to unauthorized practice of medicine. For example, in 1920 Dr. Holms stated that:

“Only the properly trained physician who has acquired surgical techniques with specialty training in obstetric physiology and pathology is competent to circumvent the many ills of childbirth.”

However these policies and practices trigged other problems, starting with the clinical training of medical students in a surgical discipline. Such training requires an acute-care hospital setting and dependable access to clinical material —  “teaching cases”. At that time, poor or immigrants hospital patients became teaching ‘material’ for medical interns and residents in return for receiving free medical care. As an up-and-coming surgical discipline, the new obstetrics required access to a steady supply of hospitalized maternity patients, which created yet another reason for the medical profession to be sharply at odds with midwives and the childbearing women who used their services. Doctors believed that every midwife-attended birth was a tragic “waste of clinical material”:

“I should like to emphasize what may be called the negative side of the midwife. Dr. Edgar states that the teaching material in NY is taxed to the utmost. The 50,000 cases delivered by midwives are not available for this purpose. Might not this wealth of material, 50,000 cases in NY, be gradually utilized to train physicians?” [1911-D, p 216]

“Another very pertinent objection to the midwife is that she has charge of 50 percent of all the obstetrical material [teaching cases] of the country, without contributing anything to our knowledge of the subject. As we shall point out, a large percentage of the cases are indispensable to the proper training of physicians and nurses in this important branch of medicine..” [1912-B, p.224]

“In all but a few medical schools, the students deliver no cases in a hospital under supervision, receive but little even in the way of demonstrations on women in labor and are sent into out-patient departments to deliver, at most, but a half dozen cases.

When we recall that abroad the midwives are required to deliver in a hospital at least 20 cases under the most careful supervision and instruction before being allowed to practice, it is evident that the training of medical students in obstetrics in this country is a farce and a disgrace.

It is then perfectly plain that the midwife cases, in large part at least, are necessary for the proper training of medical students. If for no other reason, this one alone is sufficient to justify the elimination of a large number of midwives, since the standard of obstetrical teaching and practice can never be raised without giving better training to physicians.” [1912-B, p.226]

Another glitch in their efforts to eliminate the practice of midwives and to convince pregnant women willing come to hospital and become ‘teaching cases’. One of the few voices of opposition by physicians to this ambitious plan was from Dr. Josephine Baker. At the time she was speaking the 1911 meeting of the American Society for the Study and Prevention of Infant Mortality, she had been in charge of midwifery training program at NYC’s now infamous Bellevue Hospital.

In regard to hospital-based practice of obstetrics, in particular the use of healthy maternity patients as ‘clinical material’, Dr. Baker pointed out that most of the maternity patients she and her mfry students provided care to did not want to be ‘practiced on’ by fresh-faced medical students. They object for two reasons that Dr. Baker saw as legitmate areas of concern for her patients. The first was the lack of experience by the generally all-male student body. Based on their gender had not had given birth themselves and do to their age, they didn’t have a wife or children. In the opinion of these experience mothers, medical students and interns knew next to nothing about their patient’s experience of childbirth and the duties of being a new mother.

An equally if not more important point was the extremely restrictive scope of care received from medical practitioners. Compared to midwives who provide care in the mother’s own home, the categories of medical students and graduate physicians didn’t meassue up. While the doctor’s charge for their services as a birth attendant was generally comparable to the midwife’s ($2 to $20 dollars), neither the physician or the medical students would  stay with them during the many, often tedious hours of labor.

Instead the doctor or student came, did a vaginal exam, said “your baby is not ready to come yet” and then left again. Medical care was limited to the few minutes when the baby was born and the placenta was delivered. As soon as these medical duties were concluded, doctors and medical students both made a hasty retreat.

They did not stay around to help the newly delivered mother, to bathe and care for the newborn, or see that food was prepared or available for the family. They did not return every day for a week or two to check on the new mom and baby, answer questions and even occasionally help with the housework or prepare food. Women complained that the cost of a doctors care was as much or more than a midwife, but they did not get what was very important to them — the helpful presence of their birth attendant during the hours of labor and his or her help during the days immediately following the birth. As far as they were concerned, all this was a bad deal and they wanted nothing to do with hospital birth, being a practiced on by medical students or having to fend for themselves after the baby came.

Nonetheless, influential leaders in the field were firmly convinced that the new obstetrics should be provided in a hospital under surgical conditions by physicians who were licensed to practice both medicine and surgery. This was a bold move, considering the prevalence and seriousness of  ‘childbed fever’ in the pre-antibiotic world.

For two centuries the medical profession acknowledged among themselves that aggregating childbearing women in an institution was directly associated with a drastic increase in number of cases and virulence of puerperal septicemia. Over the course of the previous century a small but substantial number of physicians all over the world – Doctor White in England, Dr. Gordon in Scotland, Dr. Cederskjšld in Sweden and our own Dr. Oliver Wendell Holmes in Boston — had all observed, studied, written and warned of the iatrogenic nature of childbed fever. In the published transcript of the 1880-1881 session of the Edinburgh Obstetrical Society (page 8-13), a Scottish professor of obstetrics brought up “the old questions”, which was an internal controversy over the safest place-of-birth in  a pre-antibiotic world:

 “the old questions were long ago worked out by Sir J Simpson, Evory Kennedy and others of home versus hospital practice and of the greatly increased mortality of hospital as compared with home”.

In this regard, the function of lying-in wards in Europe’s great charity hospitals was identified  as two-fold. First was providing food, lodging and supportive medical care to homeless & indigent women during the last weeks of pregnancy, childbirth and the first weeks of their baby’s life.  The second role for such hospitals was to teach medical students and provide opportunities for clinical training.

He notes that:

 “maternity hospitals must exist, as much for the benefit of women at a time when they most need shelter and assistance, as for the clinical instruction which the medical student can receive there and there only. 

Nonetheless, this very narrow choice of options — hospitalizing healthy maternity patients came about because the medical profession had long ago dismissed the physiological management of normal birth by midwives in the admittedly safer environment of the family home. Those who wanted to teach the surgical skills of obstetrics would just have to live with this increased risk or find a different method to reduce the risk of contagion for hospitalized maternity patients to a tolerable level.

The new obstetrics was to replace the man-midwife with surgically-trained MD attendants who had advanced skills that midwives obviously were not trained in and could not legally employ. This included medical interventions such as narcotics and other Twilight Sleep drugs for labor pains, surgical interventions such as small rubber balloons (“boogies”) used to artificially dilate the cervix and speed up first stage labor, the ability to cut episiotomies and to use forceps to shorten second stage of labor.

In light of this new surgical focus, normal childbirth was redefined as a surgical procedure and renamed ‘the delivery’. By 1910, surgically-conducted deliveries increasingly included the use of general anesthesia — chloroform or ether.  Over the next few decades spontaneous birth, now called ‘unassisted delivery’  in the medical context, was slowly replaced by the routine use of episiotomy and forceps as the new modern standard of care for normal childbirth.

The bio-hazards of hospital birth in a pre-antibiotic era

Another problem for the fledgling discipline of surgical obstetrics was timing — it arrived on the scene more 40 years ahead of the discovery of antibiotics. During a period when there was no medical treatment for infection, hospitals were infamous for their bio-hazards and many patients unfortunately died from these nosocomial (hospital-acquired) infections. “Hospital fevers” were a particularly a risk for patients who underwent an operation, as cutting into the body or introducing surgical instruments into sterile body cavities could also accidentally carry infectious bacteria, and lead to untreatable, potentially fatal post-operative infections. The physical and psychological stresses of surgery and anesthesia were hard on the patient’s immune system and without access to antibiotics, post-operative deaths from infection were at times as high as 90%.

For maternity patients, the bio-hazards of hospitals greatly increased the maternal death rate when compared to women cared for in their own homes. Medical textbooks in the late 19th century attributed the increased mortality from puerperal sepsis to ‘aggregating childbearing women in lying-in wards’ — the idea that simply mixing women and their babies together in one place provided endless opportunities for cross-contamination among themselves and the hospital staff.

As a hospital-based discipline, bio-hazard was the number one problem for the new obstetrics. In order to have a sufficient numbers of healthy maternity patients available as teaching material, obstetricians had to reduce the puerperal sepsis rate, which in 1910 accounted for a third of all deaths in hospitalized maternity patients. If the maternal mortality rate remained unacceptably high, their professional reputations would come under attack, and not even the poorest of pregnant women would come to the hospital to have their babies. Without a steady supply of teaching cases, there could be no clinical training. Without clinical training, the new surgical discipline of obstetrics would never.

To prevent or at least reduce exposure to environmental bacteria, the two most influential leaders of American obstetrics of the fledgling obstetrical profession decided the only way and that was to “Listerized” normal birth — that is conducted it as a surgically sterile procedure.  The new policy was based on the best of intentions, with high hopes of reducing maternal mortality from puerperal septicemia by faithfully applying to childbirth the same aseptic principles used by Sir Joseph Lister, Royal Surgeon to Queen Victoria.

The concept of surgical sterility was originally developed by and named after this 19th century British surgeon (think “Listerine”). His principles of medical asepsis and his idea for ‘sterile technique’ dramatically reduced post-op mortality all over the world whenever and wherever doctors could be convinced to try them. Suddenly surgical patients could be expected to live. This make surgery into a new and extraordinary effective treatment for otherwise hopeless, painful, eventually fatal medical conditions. Surgical sterility changed the course of medical history, saved untold number of lives and rightfully earned Dr Lister the title of “father of modern surgery”.

In order to apply Dr. Lister’s ideas to normal childbirth, the 2nd & third stages of labor were renamed ‘the delivery’ and declared to be a surgical procedure performed in an operating room by a physician-surgeon using the strictest of surgical sterility techniques. However, that idea did not take the normal behavior of labor patients into account, which was very different than Dr. Lister’s surgical patients, who were rendered unconscious by general anesthesia.

A conscious woman the throes of expulsive labor could not normally lie perfectly still on the narrow OR table for the one, two or more hours of the pushing phase. All this moving around, touching sterile sheets, even grabbing the hand of the obstetrician —  threw a monkey wrench into the idea of strict aseptic technique and the physician’s attempt to maintain a pristinely ‘sterile field’. How could he or any other obstetrical surgeon claim to have impeccably maintained his sterile technique with all this moving about? How could he  reasonable argue that a streptococcus, staph and other pathogen resulting in a fatal postpartum infections for one of his patients was not his fault?

To successfully conduct childbirth as sterile procedure, it was obvious to Dr DeLee and other influential obstetricians of the era that guaranteeing an impeccable surgical technique was of primary importance. As a result, general anesthesia was used to render the laboring woman unconscious and physically inert and bringing the surgical procedure of ‘vaginal delivery’ into alignment with the standard for all other surgical procedures.  In 1912, Dr J Whitridge Williams (original author of Williams Obstetrics) said:

“In Johns Hopkins Hospital,” said Dr Williams, “no patient is conscious when she is delivered of a child. She is oblivious, under the influence of chloroform or ether.

By this time, the ‘new obstetrics’  created a new ‘meme’ for maternity care in the United States, one that turned healthy women into the patients of a surgical speciality and normal birth into a routine surgical procedure. This represented the most profound change in childbirth practices in the history of the human species.

Unintended Consequences

While the motives of the obstetrical profession were noble, these policies and practices were far from benign and in the end, did not achieve the stated goal of preventing or even reducing maternal mortality from puerperal sepsis.

Unfortunately, anesthetic gases — chloroform or ether — frequently caused a profound respiratory depression and thus were dangerous for both mother and baby. To reduce exposure to these harmful effects, doctors needed to speed things up by performing an episiotomy, using forceps to quickly deliver the baby, then manually remove the placenta and suture the perineal incision. All of these additional interventions were risky and increased the mortality and morbidity associated with normal childbirth. For babies, the problem was birth injuries due to narcotics, other drugs and anesthetics give to its mother and the traumatic delivery procedures.

For mothers, the use of anesthesia, traumatic delivery and manual placental extraction techniques all predisposed them to hemorrhage and infection. The many invasive techniques and general anesthesia was also an independent assault on the mother’s immune system, making her more likely to get an infection and less likely to survive it. Taken together, the routine use of these invasive procedures doubled the maternal death rate, sending it up from the already high level of 600 per 100,000 in the early 1900s to 1,200 by 1925.

According to Dr. Ziegler:

“As to maternal mortality, …during 1913 about 16,000 women died..; in 1918, about 23,000…and with the 15% increase estimated by Bolt, the number during 1921 will exceed 26,000.” [Ziegler, MD; 1922-A]

In the wake of the plan to eliminate midwives and successful replacement by the ‘new obstetrics’ as the routine use of surgical procedures on healthy childbearing women, the maternal-infant mortality in US rose dramatically (15% a year fro 1915 to 1925), a statistic that tracks with the increase in physician-attended births and the corresponding drop in midwife-attended births.

Edit line – 4:05 qm 12-02-20012

Medicalized Midwifery Turns into Our Contemporary System of Obstetrics Normal Childbirth

Text from the OPEM:

Unfortunately the campaign to eliminate the midwife did irreparable damage to the principles and philosophy of midwifery by insisting that “only a surgeon” could adequately or safely provide birth services. Eventually doctors began to believe their own propaganda and to preach it to the public.

As a result, the discipline of midwifery —  its principles and its skills such as ‘patience with nature’ and vaginal delivery of breech babies — has itself been inadvertently destroyed and we were left, in its place, with a national maternity care policy predicated on high-tech, hospital-based specialist care.

However, the original intent of the medical profession in the early 1900s was only to eliminate midwives, per se, and for physicians to take over the practice of  midwifery. But by arguing that every normal birth must be attended by a surgeon, the medical profession unintentionally eliminated midwifery itself in all its forms and meanings. Like trying to separate co-joined twins, the effort to sever the practice of midwifery from the practice of  midwives wound up killing both. As a supportive discipline of time-tested methods to facilitate a normal birth in healthy women, midwifery was dismissed by doctors while midwives were eliminated from the maternity care system.

This is the historical circumstance which gave rise to our current contemporary system of hospital-based obstetrics. Non-interventive supportive services as provided by midwives to healthy women was the first to go. But the medical profession eventually became a prisoner of its own propaganda campaign that touted the virtues of childbirth as a surgical procedure.  The next thing to go was discipline of midwifery as the non-surgical management of normal birth as provided by GPs and family-practice physicians.

Both these historical models were able to be displaced by pairing the ‘new’ obstetrics with the services of the hospital nursing staff. During the long, often tedious hours of labor, nurses provided care to women under influence of “Twilight Sleep” drugs (the amnesic drug scopolamine  and strong doses of narcotics).  When the semi-conscious patient was ready to give birth, they called the doctor and transferred the mother by stretcher to an operating room used for surgical deliveries.  The physician was a trained to perform the ‘delivery’ as a surgical procedure  conducted in a sterile environment on an anesthetized mother-to-be and routinely including the use episiotomy and outlet-forceps.

One might characterize this sugically-oriented situation in the language of pre-operative, intra-operative and post-operative.  The duties of the two professions of nursing and medicine are very different in regard to the performance of the operation, and the care of patients pre and post-operatively. Physician were trained and legally authorized to perform surgical procedures, while the nursing staff provides ‘pre-op’ care during the labor, support the physician during the surgical procedure by functioning as a circulating nurse who hands equipment and sterile supplies to the physician-surgeon and post-op care for the newly delivered mother and neonate.

Reduced to its fewest words, you might say that today’s obstetricians do ‘ops’, while the job of the hospital nursing staff is to do the pre and post-op.

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Part III – a work-n-progress –> Dr. J. Whitridge Williams’ Plan to fund a national system of community hospitals by electively hospitalizing healthy maternity patients